CNL cheat sheet

Definition: care coordination is the deliberate organization of patient care activities and the sharing of information among participants to achieve safer, more effective, higher-quality care.

Core activities: assess need, build a shared care plan, arrange services, coordinate across settings and providers, monitor and follow up, advocate, and document in a shared record.

Care coordination versus case management: case management is a payer-linked subset focused on resource use, cost containment, and utilization review, not the whole of coordination.

Decision rule: assign a dedicated care coordinator when a patient has two or more chronic conditions plus an unplanned admission or emergency visit in the prior six months.

Single point of contact rule: every high-risk patient has one named coordinator who owns the plan; parallel coordination by multiple services produces duplication and conflicting instructions.

Coordination-sensitive outcomes: 30-day readmissions, emergency visits, avoidable admissions, length of stay, duplicate testing, and medication discrepancies.

Minimum care plan content: patient goals and preferences, active problem list, reconciled medication list, pending tests, follow-up appointments, equipment needs, and red-flag symptoms.

Naylor Transitional Care Model: APRN-led coordination spanning hospital planning, home visits, and telephone support, shown to reduce readmissions and total costs.

Donabedian chain: structure leads to process leads to outcome; an outcome can be attributed to a structure or process change only after risk adjustment.

30-day readmission rate = (unplanned readmissions within 30 days / index discharges) x 100.

Incidence rate = (new cases / population at risk) x multiplier; device-associated infection rate = infections / device-days x 1,000.

Standardized infection ratio = observed infections / predicted infections; a value below 1.0 means fewer infections than the risk-adjusted national baseline predicts.

HCAHPS: 29 items aggregated into 7 composites plus 2 global ratings (overall hospital rating and willingness to recommend); results are publicly reported.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives); positive predictive value falls as prevalence falls.

Special-cause rules on a control chart: any point beyond three sigma, or eight consecutive points on one side of the centerline.

Risk adjustment must precede cross-unit comparison; unadjusted comparisons of mortality, falls, or readmissions confound patient severity with care quality.

Transitional care = time-limited services and coordination designed to ensure continuity and prevent avoidable complications as patients move between settings or levels of care.

Medication reconciliation is required at three points: admission, transfer between levels of care, and discharge; each compares the prior list with new orders.

Discharge bundle elements: medication reconciliation, written instructions, teach-back confirmation, a follow-up appointment (commonly within 7 days), and a phone call within 48-72 hours.

Teach-back tests the teaching, not the patient: the patient restates instructions in their own words and the nurse re-teaches any gap.

Coleman Care Transitions Intervention has four pillars: medication self-management, a personal health record, primary care follow-up, and a written list of red-flag symptoms.

High-risk transitions: ICU to floor, hospital to home for a patient living alone, emergency department to home, and skilled nursing facility to home.

Warm handoff = real-time verbal exchange with the receiving provider; cold handoff = documentation or message only and carries higher risk of information loss.

Readmission risk factors: five or more medications, prior admission, low health literacy, no primary care provider, and absent caregiver support.

Discharge destination decision uses three inputs: functional status, caregiver availability, and presence of a skilled need such as nursing or therapy.

SBAR: Situation, Background, Assessment, Recommendation; used for urgent escalation and for handoffs where the receiver must act.

CUS escalation script: 'I am Concerned, I am Uncomfortable, this is a Safety issue' - a graded assertiveness ladder used when a stated concern is not addressed.

TeamSTEPPS four teachable teamwork skills: communication, leadership, situation monitoring, and mutual support.

I-PASS handoff: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver.

Thomas-Kilmann conflict modes: competing, collaborating, compromising, avoiding, accommodating; collaborating is preferred when both the task and the relationship matter.

Closed-loop communication: sender transmits, receiver repeats back, sender confirms accuracy; without the confirmation step orders can fail silently.

Transformational leadership components: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration.

Two structured team routines: the start-of-shift huddle (planning) and the post-event debrief (learning); both are brief, structured, and documented.

Braden Scale: six subscales - sensory perception, moisture, activity, mobility, nutrition, friction/shear; total range 6-23; 18 or below indicates risk and 9 or below indicates very high risk.

Morse Fall Scale: 45 or above = high risk, 25-44 = moderate; interventions scale with the score (bed low and locked, call light in reach, non-skid footwear, hourly rounding).

CAM delirium algorithm: feature 1 (acute onset or fluctuating course) plus feature 2 (inattention) plus either feature 3 (disorganized thinking) or feature 4 (altered consciousness).

LACE index: Length of stay, Acuity of admission, Comorbidity, Emergency visits in the prior six months; 10 or above flags high 30-day readmission risk.

qSOFA: one point each for respiratory rate 22 or above, altered mentation, and systolic blood pressure 100 or below; 2 or more points signals high sepsis mortality risk.

Risk = probability of an event x severity of its consequence; rank interventions using both dimensions rather than probability alone.

Caprini VTE score of 5 or above is high risk and warrants pharmacologic prophylaxis unless contraindicated.

Reassessment is time-bound: repeat falls, pressure injury, and delirium screening at admission, on transfer, after a change in condition, and at set intervals.

Polypharmacy is commonly defined as five or more concurrent medications; screen adults 65 and older with the Beers criteria for potentially inappropriate drugs.

Five A's of evidence-based practice: Ask, Acquire, Appraise, Apply, Assess.

PICO structures a searchable clinical question: Population, Intervention, Comparison, Outcome.

Evidence hierarchy high to low: systematic reviews or meta-analyses of randomized trials, randomized trials, quasi-experimental, nonexperimental, expert opinion and quality improvement data.

Research generates new knowledge, evidence-based practice translates existing evidence into local decisions, and quality improvement improves local processes; each uses different designs and review requirements.

GRADE rates certainty as high, moderate, low, or very low after judging risk of bias, inconsistency, indirectness, imprecision, and publication bias.

Translation requires more than education: combine protocol revision, training, reminders, clinical champions, and audit with feedback.

Fidelity is the degree to which a practice is delivered as designed; measure it, because low fidelity makes an effective practice appear ineffective.

Implementation frameworks: Iowa Model (moving evidence into practice change), PARIHS (context, evidence, facilitation), RE-AIM (reach, effectiveness, adoption, implementation, maintenance).

Model for Improvement: three questions (what are we trying to accomplish, how will we know a change is an improvement, what changes can we make) plus PDSA testing.

PDSA = Plan, Do, Study, Act; test on a small scale and scale sequentially rather than piloting organization-wide at once.

Six aims (STEEEP): Safe, Timely, Effective, Efficient, Equitable, Patient-centered.

Control chart special-cause rules: any point beyond plus or minus three sigma, or eight consecutive points on one side of the centerline.

Do not tamper: adjusting a stable process in response to common-cause variation increases variation rather than reducing it.

FMEA is prospective (map the process, score severity x occurrence x detection); root cause analysis is retrospective, performed after a sentinel event.

Pareto principle: roughly 80 percent of problems arise from 20 percent of causes, so rank causes by frequency to target the vital few.

DMAIC = Define, Measure, Analyze, Improve, Control; the structured Six Sigma improvement sequence.

An aim statement must state the numeric target, the population affected, and the timeframe.